NCG080607_SW DOSA Form (2 Permits)_20220128

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NC Department of Environmental Quality
Division of Energy. Mineral and Land Resources
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Stormwater Permit Delegation of Signature Authority Form
Directions are in red
Thisform shall be used to delegate signature authority from the permit Owner (Permittee) to
another party. Only the Responsible Official defined below may submit permit applications and
reports required by the permit (such as Data Monitoring Reports and Annual Reports) until this
form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility for permit
compliance.
The permit Owner is the legal entity to which/whom a permit has been issued, and may be an individual
or an organization such as a company or government agency- Every Owner is required to have a
Responsible Official who meets the legal signature authority requirements in 40 CFR 122.22, summarized
below:
For a corporation, the Responsible Official shall be a president, secretary, treasurer, or vice-
president in charge of a principal business function_ or another individual who performs similar
functions for the corporation, or the manager of one or more manufacturing, production, or operating
facilities who is authorized to make management decisions about the facility operation -
For a partnership or sole proprietorship, the Responsible Official shall be a general partner or the
proprietor, respectively; or
For a municipality, State, Federal, or other public agency, the Responsible Official shall be either a
principal executive officer [City/County Manager] or ranking elected official [Mayor].
Even if delegated signatory authority has been delegated to another individual. the Responsible Official
retains responsibility for compliance with permit conditions-
Permittee: North Carolina Air Guard
Permit Number: �NCGO80607 Charlotte, NCG080711 New London
Responsible Official Title: Colonel Joseph H. Stepp iV/145th Airlift Wing Commander
Email Address: [e-mail] Phone. [phone]
Mailing Address: 4930 Minuteman Way
City: — — —Charlotte State:iNC I Zip: j28208
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
=> the signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Sam Ingram
Delegated Party Title:
Federal Environmental Manager
Delegated Party Organization:
North Carolina Air Guard
Email Address:
[e-mail]
Phone
704-391-4327
Mailing Address:
4930 Minuteman Way
City:
Charlotte
I State:
INC
I Zip:
128208
Signature of Delegated Party indicating
acceptance of Signatory Authority:
r'7
Date:
Delegated Party Name:
Jon G nn
Delegated Party title:
State Environmental Officer
Delegated Party Organization:
North Carolina Air Guard
Email Address:
[e-mail]
I Phone:
704-391-4136
Mailing Address:
4930 Minuteman Way
City:
Charlotte
I state:
INC
I Zip:
28208
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
_ 1,0] lZ
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature cf Delegated Party indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory Authority Form
Page 2

B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 122.22) is the appropriate
individual with the authority to sign and subrilit reports for the organization.
As the Responsible.Official,. 1,. Joseph H. Stepp IV (printed name),
have the authority to enter into this Agreement for
North Carolina Air Guard
(Owner/Organization Name).
I request that the DEMLR Stormwater Program include the persons. listed. in Part A of this form
signatory authority for the above -named permit.
I. acknowledge that I, and the persons listed in.PartA of this form. work attfor my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems..
By submitting this application, 1, Jaseph H. Stepp 1V .(printed name),
have read, understand, and.accept the terms and conditions of the stormwater permits)for
which I am the Responsible Official..
5;�
101i C ml
145th Airlift. Wing Commander
Title
ZG T/'f-I Z
Date.
5tormwater Permit Delegation of signatory Authority Form
Page 3

Georgoulias, Bethany
From: INGRAM, SAMUEL C JR GS-12 USAF ANG 145 CES/CEO <[e-mail]>
Sent: Friday, January 28, 2022 12:26 PM
To: Georgoulias, Bethany
Subject: [External] NC Air Guard Delegation of Signature Authority
Attachments: SW-DOSA-Form-20210202_Completed Jan 2022 V2 CC Signed.pdf
Bethany,
See attached DOSA form signed. I will mail out the original today.
SAM INGRAM, NCANG
Federal Environmental Manager
1451" Civil Engineering
4930 Minuteman Way
Charlotte, NC 28208
samuel.ingram.2(o)-us.af.mil
Phone: [phone]
Cell#: 704-650-8620
Virtual Environmental Mgt Office Link
https://i nteIsha re. i ntel i n k.gov/sites/vemo/mcenti re/SitePages/Home.aspx